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Independents' Day

Fixated patient will only see you

Mrs Smith tries to see you wherever possible ‘because you know me, doctor’, and is unhappy about changes in practice services that have made this more difficult. These changes were introduced so the practice could manage demand and meet access targets, but they have undoubtedly affected continuity of care.

Mrs Smith tries to see you wherever possible ‘because you know me, doctor', and is unhappy about changes in practice services that have made this more difficult. These changes were introduced so the practice could manage demand and meet access targets, but they have undoubtedly affected continuity of care.

You have become aware that Mrs Smith has learnt to beat the system. She has worked out which day you are duty doctor, and her ‘emergencies' always arise on that day (and she often insists on a visit).

When her angina review falls due, she comes to see you, claiming she doesn't feel confident going to the heart-disease clinic run by the practice nurse.

Today she calls you because she has had chest pain for two hours – last week when you were on holiday. She didn't call anyone then because she ‘only trusts you'.

1 Dr Elizabeth Scott

‘Obsessive and dependent patient spells trouble'

At first sight, it appears Mrs Smith is nostalgic for the old-fashioned concept of a family doctor dedicated to her care, but her behaviour convinces me she is becoming fixated, not just reacting to practice service changes.

‘Dr Bumble is the only one I'll see because he/she is so kind and is the only person who understands me' can readily become ‘Dr Bumble used to see me alone at home almost every week and have me take my clothes off' when you try to escape her fixation and Mrs Smith complains to your PCT.

She is an obsessive, dependent personality and you made the mistake of responding to her flattery with personal attention. I bet your senior partner, who looks at every patient as if they have galloping nits and insists on a chaperone before he touches anyone, never has this problem.

The trick is to escape without receiving a formal complaint and still keep the woman on your list. Bring it up at the next team meeting. They may think you are a silly ass for getting in to this situation, but they can help.

Ask the cardiac nurse to join you for Mrs Smith's next appointment and there explain the new practice policy is for cardiac follow-up to be undertaken by the nurse.

Invite the nurse, with Mrs Smith's permission, to perform the examination and give her opinion about further care to you and Mrs Smith. You can then concur and suggest Mrs Smith makes an appointment on the way out to return to the nurse-run cardiac clinic.

If she remains with the practice, see her in the presence of a chaperone. Obsessions seldom thrive with three people in the room.

When she asks for a house call on your duty day, have the receptionists poised to agree the call and, as arranged at the team meeting, alert another doctor to go. He can tell her clearly that house calls are for emergencies and choosing the attending doctor is not an option. Should her call be unnecessary, he can discuss why she made it and offer to refer her to a psychiatrist if he feels this is necessary.

Just make very sure Mrs Smith has not got a treatable cardiac condition that everyone has missed. It may waste practice funds, but a report from a cardiologist supporting your treatment regime is comforting.

I once had a patient who kept asking for me ‘because I listened'. She used to ring reporting a fall but was always fit and undamaged when I visited. However, a despairing referral to a cardiologist and a 24-hour ECG followed by a pacemaker was curative. I was pleased I had listened.

Dr Elizabeth Scott is a GP in private practice, interested in sleep problems

2 Dr Rodger Charlton

‘Are changes really patient-centred?'

GPs prefer to be liked but it is important to prevent patients becoming dependent on us. Sometimes we think we are indispensable, but we are not. Colleagues worry about going part-time or moving practices and ask what their patients do without them as they are the only ones who understand them. This is seldom the case.

However, I am the first to support continuity of care and it is the same for me when I choose my dentist or garage.

Mrs Smith seems to have become doctor-dependent and transfixed that only you can help her. More than this, she is using your time inappropriately for visits and by shunning the heart-disease clinic and you should gently try to discuss this with her.

As we move to an era of ‘supersurgeries' where it will be difficult to see the same doctor twice I sympathise with Mrs Smith who may well be lonely and frightened and have implicit trust in you. Who knows; we too could be in a similar situation one day. The one hard-to-measure area of general practice is the therapeutic benefit of a good doctor-patient relationship and continuity of care and its importance may be overlooked.

Doctors and patients find it hard to adapt to the continuing relentless change and to conform to protocol-driven care. This uses other team members and GPSIs as we cater for the specialist clinics such as the heart disease clinic. With these and meeting access targets of people wanting to be seen on the same day, access to doctors of choice is reduced. Booking ahead with you for Mrs Smith may therefore be difficult and the result is Mrs Smith's case and limitation of choice.

No wonder she is working out the system to see you. It begs the question whether the current changes are really patient-centred. The advent of GPSIs may also mean you becoming deskilled in cardiovascular medicine. Nevertheless, you must freshly reassess the recent cause of her episode of chest pain that she has called with as you would for any other patient.

Dr Rodger Charlton is a GP and associate professor at Warwick Medical School

3 Dr Joanne Harris

‘Situation has gone too far'

Mrs Smith sounds like a classic highly dependent patient. In my experience this sort of patient often comes to each appointment bearing gifts and making it even harder to refuse her. While initially her faith in you is flattering, it is important to not collude with the patient by agreeing to all her requests. The situation has now gone too far with her ignoring serious symptoms while you are on holiday.

I would call her in for a serious chat, explaining that the pain she had had last week may be due to a heart attack. This may scare her enough into realising her behaviour was inappropriate.

Although I am delighted that she feels comfortable with me as her doctor, I am unable to be in the surgery 24-hours a day and some of her health care will need to be carried out by other members of the practice team.

She may have a valid concern about the lack of continuity of care, concerns possibly shared by doctors who are forced to adopt the changes due to political incentives. However, we all need to work with this system and taking time to explain the need for changes may be helpful.

Some of her behaviour could be borne out of a lack of control over her health care which she finds rather frightening and makes her a resistant to change. She may be genuinely unaware of the role of the practice team and the extended role of nurses in many nurse-led clinics.

I would ask if there were particular reasons why she did not want to see one of the other partners. If there is some problem, a suggestion to see the registrar or salaried partner (‘we've got a lovely young new doctor') often goes down well. It may be useful to ask the nurse or other doctor to come in for a minute just to be introduced. The appointment for the next angina clinic could be made there and then. This will make Mrs Smith more confident to come back and see someone else.

The dependent Mrs Smith would probably appreciate all the attention being foisted on her at this point and it would be time to explain visits are only for the genuinely houseound and address her misuse of emergency appointments. Sometimes this sort of dependency can be managed by setting up regular 10-minute appointments. For eaxample: every two weeks with me, plus regular reviews with the practice nurse. However, in reality her behaviour may only change temporarily before she is back to her dependent ways.

Dr Joanne Harris is a GP locum in Ealing

Learning points

Have recent changes to general practice resulted in less personal care?

• Targets on 48-hour access were introduced before the new GMS contract with significant financial rewards

• Many practices adopted the advanced access system to achieve this. This involves keeping sufficient appointments available each day to meet expected demand on the day and avoiding the need for booking in advance

• Patients are seen more quickly but it makes it harder to see the doctor of their choice, or make planned appointments, especially for those with chronic illness

• New incentives are now being proposed for practices offering advanced booking alongside 48-hour access.

• The development of GPs with particular interests within a practice, and nurses with high competence in chronic disease management, also makes personal continuity harder to achieve. This is because patients are expected to attend different people for different problems. Doctors concentrating on particular disease areas are also less available to the rest of their patients

Does it matter?

• Personal continuity has always been considered a core value in general practice.

• Recent studies confirmed that patients seeing the same doctor are likely to be more satisfied, more likely to be compliant to advice, less likely to be admitted to hospital and less likely to make a complaint about the doctor

• Doctors feel that knowing the patient better results in trust and an ability to recognise early signs of illness

• GPs and nurses with more specialised skills have the potential to manage more complex conditions in primary care, resulting in better continuity with the practice but less continuity with an individual doctor

Dependent patients

• This group was identified as a subgroup of ‘hateful patients' by Groves in 1978 and called ‘dependent clingers'. They consult frequently with excessive gratitude for the attention you give them but fail to recognise the negative feelings they engender within the doctor. They tend to present poorly defined problems and then fail to take responsibility for decisions affecting their lives, choosing instead to let the doctor do this

Why try to modify this patient's behaviour?

• This patient is wasting a valuable resource – you

• As well as reducing your job satisfaction and increasing your workload, she is impacting on the work of the rest of the practice, especially if you are being called out on unnecessary home visits. She is denying herself good anticipatory care by not seeing the nurse for chronic disease management and may run the risk of not being taken seriously when she really is ill

How can her behaviour be modified?

• Try to recognise the psychological and social aspects of the patient's illness and recognise your own part in the dysfunctional relationship

• Do you allow her to be dependent by always giving your solutions to her problems?

• If she is making you feel frustrated, recognise these feelings and tell her how her behaviour is making you feel

• Make it clear the nurse has more skill in managing her heart condition than you

• Consider setting rules about how often she sees you and perhaps agree appointments in advance

• Use a team meeting to formulate a practice policy for the patient and for peer support

• Sitting down and telling the story of your consultations with the patient may allow you to change your own narrative by recognising the potential for positive change

Dr Richard Stokell is a GP and trainer in Birkenhead, Merseyside

Dr Rodger Charlton Dr Elizabeth Scott Dr Joanne Harris

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